Child Accidents and Injuries in the North West/media/phi-reports/pdf/2013_03...while for road...

Child Accidents and Injuries in the North West March 2013

10 key points from this report

• Accidents and injuries are a leading cause of preventable death and ill health among children and young people, estimated to cost the NHS over £275 million annually, including £146 million in attendances at accident and emergency (A&E) departments. Research suggests that better partnership working across organisations and engaging with parents are key means of preventing childhood accidents. National Institute for Health and Clinical Excellence (NICE) guidance estimates that interventions such as installing home safety equipment can lead to considerable cost savings in terms of, for example, reductions in overall hospital admissions or A&E attendances for unintentional injuries.

• Nationally, deaths from accidents have declined in the last five years, particularly among those aged 10-14 and 15-19 years. Two-thirds of accidental deaths are caused by transport accidents, but causes vary by age group.

• Emergency hospital admissions for accidents in the North West are the second

highest of any region and there appears to be an increase in admissions among the under 5s. The rise in admissions is being driven particularly by an increase in the emergency admission rate among those aged 0 and 1 year of age.

• Falls account for more emergency admissions and ambulance call-outs for

accidents across the North West than any other cause. • The vast majority of emergency hospital admissions for accidents are for three days

or less. Stays of longer than three days tending to be the result of transport accidents or exposure to smoke, fire and flames.

• The rate of attendances at A&E for burns and falls are highest among the under 5s,

while for road traffic accidents it is the 15-19 year age group.

• There is evidence of considerable inequalities. Males and those from the most deprived areas in the North West are the most likely to die from accidents, be admitted to hospital with an injury or call-out an ambulance.

• Better standardisation and consistency, particularly in the collection of A&E data,

would greatly enhance the quality of the available intelligence base.

• Given the findings in this report, local authorities and Health and Wellbeing Boards should prioritise interventions and actions designed to reduce the numbers of children who are injured through falls across the region (especially among the youngest age groups) and through road traffic accidents (particularly among the oldest age groups).

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Table of Contents

1. Introduction ....................................................................................................................... 5

2. Policy and context ............................................................................................................. 8

3. Presentation of data: overview ......................................................................................... 10

4. All unintentional injuries .................................................................................................... 12

4.1 Deaths ...................................................................................................................... 12

4.1.1 Regional rates .................................................................................................... 14

4.1.2 Gender .............................................................................................................. 15

4.1.3 Age .................................................................................................................... 15

4.1.4 Deprivation level ................................................................................................. 16

4.1.5 Causes of death ................................................................................................ 17

4.1.5.1 Cause of death by age ............................................................................... 18

4.2 Hospital admissions .................................................................................................. 19

4.2.1 Regional rates .................................................................................................... 21

4.2.2 Local rates ......................................................................................................... 22

4.2.3 Gender .............................................................................................................. 24

4.2.4 Age .................................................................................................................... 24


4.2.6 Type of injury ..................................................................................................... 27

4.2.6.1 Type of injury by age group ........................................................................ 29

4.2.6.2 Type of injury by gender ............................................................................. 32

4.2.7 Length of stay .................................................................................................... 34

4.3 Accident and Emergency (A&E) attendances ............................................................. 35

4.3.1 Gender .............................................................................................................. 36

4.3.2 Age .................................................................................................................... 36

4.3.3 Attendances by hospital ..................................................................................... 37

4.3.4 Type of injury ..................................................................................................... 37

4.3.5 Time of attendances .......................................................................................... 40

4.3.5.1 Month of year ............................................................................................. 40

4.3.5.2 Day of week ............................................................................................... 40

4.3.5.3 Time of day ................................................................................................. 41

4.3.6 Other intelligence ............................................................................................... 42

4.4 Ambulance data ........................................................................................................ 43

4.4.1 Local rates ......................................................................................................... 44

4.4.2 Gender .............................................................................................................. 47

4.4.3 Age .................................................................................................................... 47

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4.4.5 Type of injury ..................................................................................................... 48

4.4.5.1 Type of injury by age group ........................................................................ 49

4.4.6 Time of call-out .................................................................................................. 51

4.4.7 Ambulance call-outs due to poisoning ............................................................... 53

4.5 Road traffic injuries .................................................................................................... 54

4.5.1 Regional rates .................................................................................................... 54

4.5.2 Local rates ......................................................................................................... 58

4.5.2.1 All road casualties ....................................................................................... 58

4.5.2.2 Killed or seriously injured road casualties .................................................... 60

4.5.2.3 Pedestrian casualties ................................................................................. 62

4.5.3 Gender .............................................................................................................. 64

4.5.4 Age .................................................................................................................... 64


4.5.6 Road user type .................................................................................................. 66

5. Summaries by injury cause .............................................................................................. 68

5.1 Falls .......................................................................................................................... 68

5.2 Road traffic collisions ................................................................................................ 68

5.3 Burns, scalds and exposure to smoke, fire or flames ................................................. 69

5.4 Other injuries ............................................................................................................. 70

6. Accidents and injuries by age group ................................................................................ 72

7. Appendices ..................................................................................................................... 76

8. References ...................................................................................................................... 80

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1. Introduction

While diseases are the main cause of death among the very young, it is unintentionali injuries or ‘accidents’ that kill more children and young people over the age of five across the world than anything else.1 The World Report on Child Injury Prevention shows that unintentional injuries account for around 90% of all childii deaths due to violence and injury each year.2,3 In the United Kingdom (UK), injuries are also the main reason why children are admitted to hospital every year and around one third of all visits to accidents and emergency (A&E) departments for injuries are by children.4 The total burden of unintentional injuries upon health services is therefore considerable, especially where children are left with a long-term disabilities or disfigurements which require a lifetime of support or treatment.3 For example, accidents that occur in childhood are estimated to cost the NHS around £146 million per year in visits to Accident and Emergency (A&E) departments alone and half of these injuries take place in the home.4 This report is part of the Child and Maternal Health Observatory (ChiMat) work programme in the North West. Its aim is to support local authorities, the NHS and Health and Wellbeing Boards in their work to prevent and minimise the risk of child accidents and injuries across the North West. The report shows the nature and scale of childhood unintentional injuries and accidental deaths across the North West, as well as within local areas, using the latest available data and intelligence. It highlights the potential to reduce the number of children who are the victims of accidents across the region each year. For the first time, the report brings together data from five sources: mortality data, hospital admission statistics, accident and emergency attendances, the North West Ambulance Service records and STATS19 (police incident) information. Figure 1: Injury Pyramid - unintentional childhood injures

Source: World Health Organization Unintentional injuries are typically classified according to their cause, such as poisoning, burns and scalds, drowning, falls or transport-related incidents.5 The injuries that lead to fatalities tend

i Unintentional injuries include those resulting from for example falls while intentional injuries include homicide and interpersonal violence, wars and other forms of collective violence, and suicide and other forms of self-harm and are not the focus of this report. ii Child defined as under 18 years.

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to be different to those that cause non-fatal outcomes: road traffic injuries are the leading cause of death among young people aged 15-19 years and the second leading cause among the 5-9 years and 10-14 years age groups.1 However, falls are found to be the most common cause of hospital admissions for unintentional injuries among children.6,7 Falls from a height tend to be associated with the most serious childhood injuries and there is evidence that older children are more likely to sustain fractures than younger ones.6 There is also evidence that (where place of injury is known) accidents occurring in the home are responsible for over 80% of emergency hospital admissions for unintentional injuries among under 5s (excluding transport accidents), while it is 50% for under 18s.8 Although child deaths from injury are on the decline there are considerable inequalities.9 Children from the poorest families are three times more likely to be admitted to hospital with accidental injuries than their wealthier counterparts and children from families with unemployed parents or parents who have not worked for a long time are 13 times more likely to die as a result of accidents.8,10 Children from the poorest families are also 38 times more likely to die from exposure to smoke, fire or flames than children whose parents work in higher managerial or professional occupations.11 Previous research shows that the North West has some of the highest rates of child deaths from accidents of any region in England.9 Reducing the number of children who die or who are injured through accidents is therefore a key means of improving health and reducing inequalities.4,12

Further factors associated with accidents can include social ones such as family stress and critical life events (e.g. hospitalisation or chronic disease of a parent, or a change of residence).13 There are also differences by age group; poisoning, drowning and burns tend to affect younger children, while road traffic accidents tend to occur more among older children and adolescents. Further differences exist by gender and geographical area; for example boys are more likely to be involved in accidents than girls and rural areas tend to experience greater incidence of drowning, while road traffic accidents or falls are more prevalent in the more urban areas. Some recent evidence also shows that risk from unintentional injuries reduces with increased age of the mother.14 Many of the accidents that occur among children and young people are preventable or can be controlled. There is a variety of evidence about ‘what works’ in reducing death or ill health through injuries and the case for taking preventative action is compelling. For example, the World Health Organization (WHO) showed that countries who implemented injury prevention interventions cut their adolescent injury mortality rates by over 50 per cent in some cases.

Therefore, WHO estimate that thousands of lives could be saved every day through evidence based interventions.5

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Table 1: Headline national figures for child accidents each year Annual NHS spend on childhood accidents £275 million Annual NHS spend on emergency childhood admissions for accidents

£131 million

Annual number of children aged under 5 years admitted to hospital due to accidents (excluding transport accidents)

35,000 (equivalent to 4 every hour)

Annual number of under 4s admitted to hospital as an emergency admission due to falls in England

16,000 (45 every day)

Annual number of children aged under 16 years attending A&E with a head injury in England (1 in 10 of these are moderate to severe)

295,000

Annual NHS spend on inpatient treatment for children and young people with hot drink scalds

£2.2 million

Annual number of children killed or seriously injured on Britain’s roads

2,412 (equivalent to 7 children

every day) The annual cost of road accident fatalities and serious injuries among 0-15 year olds.

£547 million

Source: Child Accident Prevention Trust (CAPT) factsheets. See: www.makingthelink.net/tools/argument-action www.makingthelink.net/tools/costs-child-accidents www.makingthelink.net/topic-briefings/housing-and-home-environment www.capt.org.uk/who-we-are

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http://www.makingthelink.net/tools/argument-action

http://www.makingthelink.net/tools/costs-child-accidents

http://www.makingthelink.net/topic-briefings/housing-and-home-environment

http://www.capt.org.uk/who-we-are

2. Policy and context

At the time of writing this document, the public health system in England is going through a period of considerable transition. This includes the creation of a new organisation – Public Health England – which will come into effect from April 2013. At the same time, public health will become embedded within local government structures, building upon and strengthening their existing role in protecting and improving the nation’s health and wellbeing.15 Locally led services, accountable decision making and best use of available evidence will form core principles of the new system. It is envisaged that placing public health within local authorities will also help to better tackle the wider determinants of health and health inequalities, such as employment, local environments and housing.16 Although areas are able to set their own localised targets a number of mandatory services will have to be provided (such as sexual health services and the National Child Measurement Programme). The wider changes in health as part of the Health and Social Care Act 2012 include the formation of 211 clinical commissioning groups (CCGs) across England (replacing primary care trusts) to act as independent statutory bodies led by GP practices and be responsible for £65 billion of the £95 billion NHS commissioning budget.17 It is therefore important that CCGs and local authorities work together under the new arrangements, perhaps through joint commissioning agreements, to deliver effective health improvement services as part of the healthcare available in their areas.18 In the new public health system in England there are plans for a continuing focus upon preventing accidents among children. There will be set targets against which the progress of every local authority will be measured as part of their new role and responsibilities. Specifically, the Department of Health has already announced that, under domain two of the new Public Health Outcomes Framework (PHOF) 2013-2016, there will be an indicator to reduce childhood injuries through hospital admissions caused by unintentional and deliberate injuries in under 18s.iii,19,20 The new framework is also going to feature an all age indicator to reduce the numbers of people killed or seriously injured on the roads each year. As outlined in their recently released Guide to Commissioning for Child Accident Prevention, the Child Accident Prevention Trust (CAPT) note that there is considerable opportunity within the new structures to commission and build effective childhood accident prevention services.21 For example, although from April 2013 until 2015 the NHS Commissioning Board will be responsible for commissioning public health services for 0-5 year olds, it is local authorities that will measured against the PHOF to reduce childhood hospital admissions for accidents. Similarly, the Royal Society for the Prevention of Accidents’ (ROSPA) Big Book of Accident Prevention shows that accidents are the main cause of premature, preventable death and therefore the local Health and Wellbeing Boards should ensure that accident prevention remains high on local agendas.22

Previous work at a national level has found that it can be difficult to accurately measure the scale and severity of unintentional injuries due to limitations in the collection, use and sharing of relevant data, for example from A&E departments.7 The relatively recent addition of A&E data into the main Hospital Episode Statistics (HES) database is a welcomed step towards improving surveillance of injury in children.7

iii The age breakdowns will be 0-4 year olds and 5-17 year olds. 8

Partnership working is critical in increasing the profile of injury prevention in local areas and making the economic argument for taking action is an important factor in successfully tackling and reducing accidents.7 Previous research has found a lack of coherence between housing policy, planning and public health, with greater joint working needed if the links between deprivation and unintentional injury are to be addressed.7 Partnership working is also identified as a key feature in helping to engage and educate parents for example through sharing of best practice among children’s centres, health visiting teams, family nurse partnership programmes and fire and rescue service teams.7 Methods or interventions to prevent accidents are not the focus of this report, however some relevant information is available in the appendices at the end of this document to summarise evidence about successful or promising interventions.2 Recent advice from CAPT’s Making the Links campaign, for example, highlights that engaging with parents is a key aspect of preventing accidents among children and young people.23 However, barriers include differing views about the prevention of accidents, a perception that preventing accidents costs time and money, limited understanding about the causes of some serious injuries among children and being taken by surprise when young children take sudden and unexpected steps in their physical abilities.7 For example, in the Parents Under Pressure survey conducted by CAPT (as part of Child Safety Week 2012), 44% of parents thought that they could not do anything to prevent accidents from occurring and in some cases parents/carers underestimated the seriousness of potential injuries upon their child’s health and wellbeing, and that of the wider family (such as from hair straighteners or hot water scalds).23 CAPT have also produced some useful information resources such as a One Step Ahead wall chart to help inform parents, particularly of very young children, about accidents in the home. The National Institute for Health and Clinical Excellence (NICE) examined the evidence and best practice for reducing accidents among children and young people aged under 15 and produced a set of recommendations focussed upon how to appropriately plan and coordinate programmes and particular interventions to improve safety on the road, in the home and outdoors.24,25 A NICE report examining the costs of accidents showed that reducing injuries per 100,000 population by 10% would save more than £47,000 in hospital admissions and emergency department attendances locally each year.24 The guidance focuses upon recommendations that local authorities and their partners are likely to find most costly to implement and those which can potentially generate considerable savings such as through coordinating unintentional injury prevention activities and delivery of home safety assessments or installation of home safety equipment.

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3. Presentation of data: overview

There is currently no agreed way of classifying children using particular age categories or boundaries. For example, the World Report on Child Injury Prevention3 examines injuries among children aged 0-18 years in line with the definition used by the Convention on the Rights of the Child. However, not all data are available to this level and further categories are used in the report such as for those aged 0-20 years. The same pragmatic approach is taken within the European Report on Child Injury Prevention which accompanies the world report.1 The recent Report of the Children and Young People’s Health Outcomes Forum recommended that there is an urgent need for all data relating to children to be presented by five-year age band.26 This would allow comparison of key measures across countries, as well as national or local comparisons at times of major transitions in a child’s life such as starting secondary school or moving into adulthood. This report therefore presents data on accidents and injuries in the North West by five-year age band to help highlight any differences in risk from particular injuries at specific points in a child’s life. As a result, data are examined for those aged from 0 up to and including 19 years of age. The results that follow firstly present unintentional injury data for deaths, emergency hospital admissions, A&E attendances, ambulance data and STATS19 police incident data. In each section, the different datasets are then split by, where available, trends, regions, local areas, gender, age (in five year bands), deprivation and particular injury or accidental cause. For admissions data the length of stay is also examined. The availability and consistency of information varies considerably across datasets and over time. Therefore, where the number of cases was small, data had to be combined across more than one year to make numbers sufficient for analysis. In the case of deaths data, numbers of accidental deaths are too small to examine at the regional level, therefore some of this data are examined at national level only. Where this is the case, the data used are indicated in the text. Certain datasets such as for A&E attendances are locally collected and therefore just relate to the North West. Also, while some datasets are presented for fiscal years, others are for calendar years. In all cases, the most recent available data has been used and information on trends over time provided. Therefore, the deaths and emergency hospital admissions data cover the five year period from 2007 to 2011. The STATS19 police incident data and ambulance service data are for the three years from 2009 to 2011 and the A&E data is for 2011 only. Throughout the report where rates are presented for children and young people (aged 0 to 19 years, and in some instances split by five-year age band) these are crude rates per 100,000 population. Confidence intervals indicate the reliability of the survey results. Sample surveys are always subject to some error, but it is possible to be 95% confident that the true result for the particular population segment in question is within the confidence limits calculated. In other words, where one measure is ‘significantly’ higher or lower than another, we are 95% confident that this is not due to random error or chance. It is possible to explore the relationship between deprivation and accidents in the North West by grouping very small geographies together by deprivation level. Lower super output areas (LSOAs, areas with a minimum total population of 1,000 and a mean total population of 1,500)

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throughout the North West can be grouped into one of five categories depending on their relative national deprivation level in the Index of Multiple Deprivation (IMD) 2010 (ordered from the least deprived national fifth of areas to the most deprived national fifth of areas). The IMD 2010 combines a number of indicators, chosen to cover a range of economic, social and housing issues, into a single deprivation score for each small area in England.

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4. All unintentional injuries

4.1 Deaths

The data in this section refers to deaths from an accident or unintentional injury. Mortality counts are derived from an annual mortality extract supplied by the Office for National Statistics (ONS) and are based on the original underlying cause of death for which there is nearly 100% coverage on the mortality register. Deaths included are those classified in the mortality dataset as International Classification of Diseases (ICD) 10 external cause codes V01-X59, which is in line with the method used to produce the Deaths from unintentional injury indicator in the Injury Profiles for England.iv Between 2007 and 2011, 335 North West children and young people aged 0-19 years died as a result of accidents, an average of 67 per year. This represents one in eleven (9.0%) of all deaths among children and young people of this age. Over this period, the number of accidental deaths among those aged 0-19 years in the North West accounted for 13.5% of all accidental deaths in this age group across England. Data from the last five years shows that the overall mortality rate from accidents among children and young people aged 0-19 years has decreased by 45.4% across England (from 5.1 to 2.8 per 100,000 population). The reduction in the mortality rate is more evident among the older age groups (a decrease of 56.0% and 47.6% for those aged 10-14 years and 15-19 years respectively from 2007 to 2011) than the younger age groups (decreases of 23.4% and 31.5% for those aged 0-4 years and 5-9 years respectively) (Figure 2). Although numbers in the North West are not high enough to provide meaningful figures by age group, the overall mortality rate in the region fell by a similar proportion (a 41% decrease) over the same period.

iv Further details about the profiles are available from: www.apho.org.uk/default.aspx?QN=INJURY_DEFAULT 12

http://www.apho.org.uk/default.aspx?QN=INJURY_DEFAULT

Figure 2: Crude mortality rate from accidents (0-19 years) per 100,000 population by five-year age group. England, 2007 to 2011.

Source: NWPHO from Office for National Statistics mortality dataset and mid-year population estimates

0

2

4

6

8

10

12

14

16

0-4 years 5-9 years 10-14 years 15-19 years

Rat

e pe

r 100

,000

2007 2008 2009 2010 2011

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4.1.1 Regional rates

In 2007-11, the North West mortality rate from accidents among those aged 0-19 years was the third lowest in England, and equalled the national mortality rate (4.0 per 100,000 population) (Figure 3). While the rate for most regions was not significantly different to the England average, the mortality rate in Yorkshire and the Humber was significantly higher and the rate in London was significantly lower than the national average. Figure 3: Crude mortality rate from accidents (0-19 years) per 100,000 population. English regions, 2007-11.

Source: NWPHO from Office for National Statistics mortality datasets and mid-year population estimates

0

1

2

3

4

5

6

North East North West Yorkshire and the Humber

East Midlands

West Midlands

East of England

London South East South West

Rat

e pe

r 100

,000

England average and CIs

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4.1.2 Gender

Almost three-quarters (73.1%) of accidental deaths among those aged 0-19 years in the North West between 2007 and 2011 were among males. This equates to a male mortality rate of 5.7 per 100,000 population compared with a female mortality rate of 2.2 per 100,000, a significant difference. 4.1.3 Age

Of the 335 accidental deaths among children and young people aged 0-19 years in the North West between 2007 and 2011, the majority (60.3%) were among those aged 15-19 years. The mortality rate for males aged 15-19 years is 4.0 times higher than males aged 0-4 years (13.5 per 100,000 population compared with 3.3) (Figure 4). Deaths among males exceeded deaths among females in each age group. The proportion of all deaths that have an accidental cause increases as age increases. Just 2.4% of all deaths among those aged 0-4 years have an accidental cause,v compared with 13.1% of those aged 5-9 years, 21.1% of those aged 10-14 years and 29.9% of those aged 15-19 years. Figure 4: Crude mortality rate from accidents (0-19 years) per 100,000 population, by age group and gender. North West, 2007-11.

Source: NWPHO from Office for National Statistics mortality dataset and mid-year population estimates

v Note this rises to 11.5% of those aged 1-4 years, due to the different nature of deaths among infants under one year.

0

2

4

6

8

10

12

14

16

18


Rat

e pe

r 100

,000

Males Females

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4.1.4 Deprivation level

Although analysis of the mortality rate from accidents by residential deprivation level across the North West is somewhat limited due to small numbers and large confidence intervals, there is some evidence that mortality is higher in the more deprived areas compared with the less deprived. In 2007-11, the mortality rate from accidents among children and young people aged 0-19 years was 1.7 times higher in the most deprived areas than in the least deprived (4.4 per 100,000 population compared with 2.6 per 100,000), and this difference was significant (Figure 5). Figure 5: Crude mortality rate from accidents (0-19 years) per 100,000, by Index of Multiple Deprivation 2010 quintile. North West, 2007-11.

Source: NWPHO from Office for National Statistics mortality dataset and mid-year population estimates and Department for Communities and Local Government (Index of Multiple Deprivation)

0

1

2

3

4

5

6

7

Least deprived Fourth most deprived Third most deprived Second most deprived

Most deprived

Rat

e pe

r 100

,000

NW average and CIs

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4.1.5 Causes of death

Accidental deaths among males were examined by ICD-10 summary group causevi at the national level due to small numbers at regional level. The results show that transport accidents are the most common cause of accidental death among children and young people aged 0-19 years in England, accounting for 63.0% of all accidental deaths (Table 2). If data are examined in more detail,vii by far the most common form of transport accident resulting in death is those where children or young people were car occupants (33.8% of all accidental deaths) followed by those where they were pedestrians (13.7%). Other external causes of accidental injury account for 37.0% of all accidental deaths among those aged 0-19 years. A significant proportion of these were due to other accidental threats to breathing (11.4% of all accidental deaths), and a further 7.2% of accidental deaths were due to accidental poisoning by exposure to noxious substances. Table 2: Causes of death among children and young people aged 0-19 years. England, 2007-11. Cause % of accidental

deaths Transport accidents Car occupant injured in transport accident 33.8% Pedestrian injured in transport accident 13.7% Motorcycle rider injured in transport accident 8.1% Pedal cyclist injured in transport accident 3.7% Other land transport accidents 2.6% Other transport accidents 1.1% Transport accidents: total 63.0% Other external causes of accidental injury Other accidental threats to breathing 11.4% Accidental poisoning by exposure to noxious substances 7.2% Accidental drowning and submersion 6.6% Falls 3.8% Accidental exposure to other and unspecified factors 2.5% Exposure to smoke fire and flames 2.2% Exposure to inanimate mechanical forces 1.6% Other external causes of accidental injury (not elsewhere specified) 1.7% Other external causes of accidental injury: total 37.0% Source: NWPHO from Office for National Statistics mortality dataset Notes: Other transport accidents includes: air and space transport accidents, water transport accidents, occupants of pick-up truck or van injured in transport accident, occupants of heavy transport vehicle injured in transport accident and bus occupants injured in transport accident. Other external causes of accidental injury (not elsewhere specified) includes: exposure to electric current, radiation and extreme ambient air temperature and pressure, exposure to animate mechanical forces, contact with heat and hot substances, exposure to forces of nature and overexertion, travel and privation.

vi See appendix for more details of the specific codes used for each. vii Using individual three digit ICD-10 cause code

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4.1.5.1 Cause of death by age

Across England, the top three causes of accidental death vary by age group (Table 3). For example, transport accidents feature as a major cause of accidental death in each age group, but more obviously so for those aged 15-19 years, as 45.7% of all accidental deaths in this age group (an average of 149 per year) are caused by being a car occupant in a transport accident. These data do not show whether the young person was the car driver or a passenger when the transport accident occurred, but this age group does encompass the time at which young people are first legally able to drive a car. The most likely cause of accidental death among those aged 5-9 years and 10-14 years is being injured as a pedestrian in a transport accident. Among those aged 0-4 years, other accidental threats to breathing is the most common cause of accidental death, accounting for over a third (34.6%) of accidental deaths in this age group. Within this summary group, accidental suffocation and strangulation in bed is the most common cause (9.0% of all accidental deaths in this age group), followed by unspecified threat to breathing (7.0%), other accidental hanging and strangulation (5.5%), inhalation and ingestion of food causing obstruction of respiratory tract (5.5%), and then other causes. Table 3: Top three causes of accidental death among children and young people aged 0-19 years, by age group. England, 2007-11. Age group

Top three causes of accidental death (% of all accidental deaths in age group, average annual number of deaths)

1 2 3 0-4 years

Other accidental threats to breathing (34.6%, 28)

Accidental drowning and submersion (15.8%, 13)

Pedestrian injured in transport accident (11.5%, 9)

5-9 years Pedestrian injured in transport accident (26.2%, 9)

Car occupant injured in transport accident (13.4%, 4)


10-14 years




15-19 years


Motorcycle rider injured in transport accident (11.0%, 36)


Total 0-19 years




Source: NWPHO from Office for National Statistics mortality dataset

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4.2 Hospital admissions

Data on hospital admissions due to unintentional injury are contained within Hospital Episode Statistics (HES). These data are currently presented in the public domain in a variety of different formats to help examine cases of accidents among children. The analyses in this section consider all those admissions classified with an external cause ICD-10 code between V01 and X59 (accidents). This approach is based upon the method used to calculate the Hospital admissions due to unintentional (accidental) injury indicator within the National Injury Profiles for England (available for the year 2010/11) produced by the Injury Observatory for Britain and Ireland (IOBI).viii The national profiles also include an additional Hospital admissions due to unintentional injury indicator which uses both external cause codes V01-X59 and injury codes S00-T73, as well as T75 and T7. However, we examined data using the former approach. Indicators specifically for children are also produced. For example, the National Injury Profiles for England include a Hospital admissions due to injury indicator for children aged under 18 (also for 2010/11). However, this includes admissions with an ICD-10 code between V01 to Y98, therefore intentional injuries such as self-harm and assault are also counted. Such injuries are outside the scope of this report and therefore we excluded these codes. A Hospital admissions due to accidents indicator is also available from the NHS Information Centre (IC) Portal. This focuses on children aged under 5 years and those aged 5-14 years. However, further examination of the data shows that this relates to serious accidents and therefore considers the duration of an admission, defining admissions as those with a length of stay exceeding three days. The indicator includes ICD-10 codes V01-X59, but it also captures further external cause codes that are not within the accident classification described above for the hospital admissions indicator, Y40-Y84 (complications of medical and surgical care). Trend data is also available but the most recent year is 2008/09 while we examined data for 2011/12.ix Data by type of injury were examined for the North West for the two main categories within ICD-10 code for accidents: i) Transport accidents (which distinguishes between for example whether a person was a

pedestrian, car occupant or a motorcycle rider); and ii) Other external causes of accidental injury (which includes falls, burns, accidental poisonings,

and so on). Hospital admission rates are residence-based and therefore relate to the population in each area who are admitted to hospital as a result of an unintentional injury no matter where the hospital is, or where the accident that caused the injury occurred.

viii For more details see: www.injuryobservatory.net ix Note that caution is advised when interpreting the results for 2011/12 due to a change in the method used by the NHS Information Centre to allocate geographies to records with missing postcodes (previously the primary care trust information was used, whereas such cases are now classed as unknown). The vast majority of records affected are birth records. In turn this may have led to an underestimation in numbers within the 0-4 year age group compared to previous years.

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http://www.injuryobservatory.net/

Between 2007/08 and 2011/12, there was no discernible trend in the rate of emergency hospital admissions for accidents among children and young people aged 0-19 years in the North West (Figure 6). The crude rate of hospital admissions was highest in 2010/11 (1,172.6 per 100,000 population) and lowest in 2008/09 (1,050.9 per 100,000 population). Figure 6: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population. North West, 2007/08 to 2011/12.

Source: NWPHO from Hospital Episode Statistics and Office for National Statistics population estimates

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4.2.1 Regional rates

There were 19,167 hospital admissions for accidents among children and young people aged 0-19 years in the North West in 2011/12, equating to a hospital admission rate of 1,134.0 per 100,000 population. The North West had the second highest regional rate of emergency hospital admissions for accidents among children and young people, following the North East (1,396.7 per 100,000 population) (Figure 7). The North West’s rate was 1.2 times, and significantly, higher than the rate for England (940.9 per 100,000 population). Figure 7: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population. English regions, 2011/12.

Source: NWPHO from Hospital Episode Statistics and Office for National Statistics mid-year population estimates

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4.2.2 Local rates

There is considerable variation in the number of emergency hospital admissions at a local level within the North West. The emergency hospital admission rate for accidents for those aged 0-19 years varies from 832.5 per 100,000 population in Fylde to 1,473.2 per 100,000 in Burnley, which is 77% higher (Figure 8, Map 1). Compared with the North West average, Fylde, Trafford, Eden, South Lakeland, Carlisle, Sefton, Stockport and Liverpool have rates that were significantly lower while Burnley, Oldham, Manchester, Salford and Rochdale all had rates that are significantly higher. However, compared with the England average, only Trafford has a rate that is significantly lower, while 26 local authorities had rates that were significantly higher than the national average. Figure 8: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population. North West local authorities, 2011/12.


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Map 1: Crude rate of emergency hospital admissions for accidents (0-19 years), per 100,000 population. North West local authorities, 2011/12.

Local authority Rate Allerdale 1,009.2 Barrow-in-Furness 1,056.5 Blackburn with Darwen 1,249.2 Blackpool 1,268.2 Bolton 1,043.4 Burnley 1,473.2 Bury 1,103.1 Carlisle 928.8 Cheshire East 1,099.9 Cheshire West and Chester 1,180.6 Chorley 1,065.5 Copeland 1,319.1 Eden 896.7 Fylde 832.5 Halton 1,172.9 Hyndburn 1,181.7 Knowsley 1,086.2 Lancaster 1,063.3 Liverpool 1,026.4 Manchester 1,360.4 Oldham 1,446.3 Pendle 1,189.4 Preston 1,151.4 Ribble Valley 1,108.2 Rochdale 1,266.5 Rossendale 1,153.8 Salford 1,326.3 Sefton 939.3 South Lakeland 924.3 South Ribble 1,024.9 St Helens 1,210.4 Stockport 991.5 Tameside 1,170.1 Trafford 833.9 Warrington 1,181.0 West Lancashire 1,101.6 Wigan 1,087.6 Wirral 1,048.8 Wyre 1,076.3 North West 1,134.0 England 940.9

Source: NWPHO from STATS19 and Office for National Statistics mid-year population estimates Crown copyright. All rights reserved. NWPHO/DH (licence 100020290). March 2013. Colour coding in the table represents the significance of the local rate compared with the North West average. Red = significantly worse; yellow = no significant difference; green = significantly better.

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4.2.3 Gender

In 2011/12, the rate of emergency hospital admissions for unintentional injuries and accidents among children and young people aged 0-19 years was 1.6 times higher for males than for females (1,375.7 per 100,000 population compared with 880.2 per 100,000). In total, 62.1% of all emergency hospital admissions for unintentional injuries and accidents among children and young people aged 0-19 years in the North West were for males.

4.2.4 Age

The rate of emergency hospital admissions among children aged 0-19 years in 2011/12 was highest among those aged 0-4 years (1,746.7 per 100,000 population), significantly higher than among any other age group (Figure 9). For example, the rate among those aged 0-4 years was 2.2 times that of the rate for those aged 15-19 years (794.3 per 100,000 population). Figure 9: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population, by age group. North West, 2011/12.

Source: NWPHO from Hospital Episode Statistics and Office for National Statistics mid-year population estimates Trends by age group

The rate of emergency hospital admissions for accidents among the very youngest individuals (0-4 years) appears to be rising (Figure 10). The increase in admissions is being driven particularly by a rise in the emergency admission rate among those aged 0 and 1 year (a 27.4% and 22.6% increase respectively between 2007 and 2011, both significant). For older age groups (5-9 years and 10-14 years) there appears to be no discernible overall trend, although the rate for 2011/12 rate for those aged 10-14 years is significantly lower than the rate in 2010/11 and 2007/08. The admission rate appears to be on a downward trend for those aged 15-19 years.

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Figure 10: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population, by age group. North West, 2007/08 to 2011/12.


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Analysis by deprivation shows that during 2011/12 children and young people aged 0-19 years living in the most deprived areas of the North West were 1.6 times more likely to be admitted to hospital because of an unintentional injury or accident than those living in the least deprived areas (1,406.3 per 100,000 population compared with 876.3 respectively) (Figure 11). Figure 11: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population, by Index of Multiple Deprivation 2010 quintile. North West, 2011/12.

Source: NWPHO from Hospital Episode Statistics and Office for National Statistics mid-year population estimatesx

x As mid-year population estimates at LSOA level are not yet available for 2011, 2010 data have been used as a substitute within the denominator.

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4.2.6 Type of injury

In 2011/12, the highest hospital admission rate for accidents by cause among children and young people aged 0-19 years in the North West was for falls (516.4 per 100,000 population) (Figure 12). Falls accounted for 45.5% of all emergency hospital admissions for accidental injuries, more than for any other cause. Information available from other sources also shows that falls are one of the most common reasons for admission.7,27 The second highest hospital admission rate for accidents was exposure to inanimate mechanical forces (201.9 per 100,000, with these admissions accounting for 17.8% of all admissions for accidents). This type of injury can include striking against or being struck by something, such as a wall, or being caught or jammed between objects, such as a door frame. The next highest admission rate was for accidental poisoning by exposure to noxious substances (80.9 per 100,000, 7.1% of all admissions for accidents), followed by exposure to animate mechanical forces (66.4 per 100,000, 5.9%) which includes being accidentally hit by another person, crushed by a crowd or being bitten by a dog. The rate of admissions for pedal cyclists injured in transport accidents was 66.3 per 100,000 and these admissions comprised 5.9% of all admissions for accidents among children and young people in the North West.

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Figure 12: Crude rate of emergency hospital admissions for accidents (0-19 years) per 100,000 population, by type of injury. North West, 2011/12.


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4.2.6.1 Type of injury by age group

The rates of emergency hospital admissions for accidents by cause vary by age group (Figure 13). While falls are the most common cause of admission for accidents in each age group, these types of injuries are more common among children aged 0-4 years (a rate of 841.8 per 100,000 population) than in any other group. Rates of exposure to inanimate mechanical forces are also highest among children aged 0-4 years (314.8 per 100,000 population). Rates of emergency admissions for accidental poisoning are highest among the youngest (0-4 years) and oldest (15-19 years) age groups: 197.0 and 71.1 per 100,000 population respectively. Emergency admissions for pedal cyclists injured in transport accidents are highest among those aged 10-14 years (124.5 per 100,000 population). The rate of emergency hospital admissions due to contact with heat and hot surfaces is highest in children aged 0-4 years (134.2 per 100,000), while car occupants and motorcycle occupants injured in transport accidents peaked at age 15-19 years. Given the predominance of falls, we examined the types of falls that were the cause of hospital admissions by age group. There are some differences in the top ten causes of falls (Figure 14). Those aged 0-4 years had admission rates that were significantly higher than for other age groups for falls on the same level from slipping, tripping and stumbling (117.1 per 100,000 population); those on and from stairs and steps (127.3 per 100,000, the biggest cause of falls among 0-4 year olds); other falls on the same level (67.0); those involving a bed (82.5); and those involving a chair (85.5). The highest hospital admission rate for falls involving playground equipment is among children aged 5-9 years (139.2 per 100,000 population), and this is also the biggest cause of falls in this age group. The highest hospital admission rate for falls on the same level due to collision with, or pushing by, another person is among 10-14 year old children (54.2 per 100,000 population), although they are more likely to fall on the same level from slipping, tripping and stumbling. Other differences not shown in Figure 14 include hospital admissions for falls while being carried or supported by other persons (with 87.7% of these admissions occurring in 0-4 year olds) and falls involving ice-skates, skis, roller-skates or skateboards (47.4% of these admissions occurred in 10-14 year olds).

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Figure 13: Crude rate of emergency hospital admissions for accidents by cause, by age group. North West, 2011/12.


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Figure 14: Crude rate of emergency hospital admissions for falls by cause, by age group. North West, 2011/12.


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Males are more likely than females to be admitted to hospital for most major accidental causes, but the difference between genders varies by cause (Figure 15), and the most common causes vary slightly by gender (Table 4).

For example, males are 3.8 times more likely than females to be admitted to hospital due to being involved in an accident as a pedal cyclist (103.3 per 100,000 population compared with 27.5) and are 13.1 times more likely to be admitted as a motorcycle rider injured in a transport accident (28.5 per 100,000 compared with 2.2). Other notable differences for hospital admission by gender include admissions as a pedestrian injured in a transport accident (39.9 compared with 21.3 per 100,000 for males and females respectively) and for exposure to animate mechanical forces (82.6 compared with 49.3), falls (626.5 compared with 400.9) and exposure to inanimate mechanical forces (242.6 compared with 159.2). Table 4: Top five causes of hospital admissions for accidents (0-19 years), by gender. North West, 2011/12. Males Females 1 Falls 45.5% 1 Falls 45.5% 2 Exposure to inanimate

mechanical forces 17.6% 2 Exposure to inanimate

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Source: NWPHO from Hospital Episode Statistics

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Figure 15: Crude rate of emergency hospital admissions for accidents by cause, by gender. North West, 2011/12.


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4.2.7 Length of stay

The National Injury Profiles include an indicator measuring the number of hospital admissions due to unintentional injuries with a length of stay that is longer than three days. In the past, this measure has been used to examine serious unintentional injury and was a target indicator in the Saving Lives: Our Healthier Nation28 strategy. However, it is important to note that staying in hospital for over three days is not always a sign of serious injury as other factors such as bed capacity or the time and resources needed to perform any associated tests or procedures, or to arrange appropriate after care might have an impact on the length of time someone is admitted. Notwithstanding these limitations, the North West data show that the majority of hospital stays for accidents during 2011/12 among those aged 0-19 years were for three days or less (95.4% of all with a known duration) with only around one in twenty (4.6%) over three days. However, the proportion varies by cause. Of the nearly 2,200 hospital admissions for transport accidents, 9.6% were for more than three days, compared with 3.9% of admissions for other accidental causes. Causes with notably high proportions of longer-stay admissions include motorcycle riders (22.5% of admissions being for more than three days) and car occupants (16.7%) injured in transport accidents, and among other accidental causes, exposure to smoke, fire and flames (17.7%).

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4.3 Accident and Emergency (A&E) attendances

Within this section information from local accident and emergency department (A&E) data for the North West is presented. This is available from the Trauma and Injury Intelligence Group (TIIG) at the Centre for Public Health, Liverpool John Moores University. Information was included for 24 hospitals in the region: • Alder Hey Children’s Hospital • Arrowe Park Hospital • Blackpool Victoria Hospital • Burnley General Hospital • Chorley and South Ribble Hospital • Cumberland Infirmary • Furness General Hospital • Leighton Hospital • Macclesfield District General Hospital • Manchester Royal Infirmary • Ormskirk District General Hospital • Royal Blackburn Hospital • Royal Bolton Hospital • Royal Lancaster Infirmary • Royal Liverpool University Hospital • Royal Preston Hospital • Royal Albert Edward Infirmary • Salford Royal Hospital • Southport and Formby District General Hospital • Stepping Hill Hospital • Tameside Hospital • Trafford General Hospital • West Cumberland Hospital • Whiston Hospital • Wythenshaw Hospital Information is not currently collected in a consistent manner across each hospital, and are held in individual datasets. The fields and related codings used within the datasets vary. We collated all the individual datasets into one dataset in the most consistent manner possible, but there are caveats. For example, it is important to note that the overall ‘other accidents or injury’ category is likely to include types of injuries specified separately elsewhere, such as falls or burns. This is due to the lack of consistent coding. Therefore, the numbers and rates for injuries, particularly specifically-named injuries, are likely to be undercounted. Nevertheless, the data provide some good intelligence, and the presentation of data here is the first time this information has been drawn together for the North West. According to data examined for the 24 hospital emergency departments in the North West, in 2011/12, there were 202,257 A&E attendances for accidents or unintentional injury at North West hospitals by children and young people aged 0-19 years. This equates to 45.2% of all

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attendances with a known cause.xi Other causes outside the scope of analysis include assault, deliberate self-harm, alcohol-related attendances and those that were ‘unknown’.xii

4.3.1 Gender

The rate of attendances for accidents is significantly higher for males than it is for females (13,514.8 per 100,000 population compared with 10,339.2). Just under three-fifths (57.8%) of attendances for accidents are by males. 4.3.2 Age

The rate of attendance is highest among children aged 10-14 years (13,739.4 per 100,000 population) and lowest among those aged 5-9 years (9,964.1 per 100,000) (Figure 16). Figure 16: Crude rate of A&E attendances for accidents (0-19 years), per 100,000 population, by age group. North West hospitals, 2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group and Office for National Statistics mid-year population estimates

xi 236,185 records were categorised as ‘other’ or ‘unknown’. xii For over 6,000 attendances, the reason for attendance was missing altogether. These data were therefore not included in the count of all attendances.

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The number of A&E attendances for accidents among those aged 0-19 years is detailed below (Table 5) and shows the burden on emergency departments. Table 5: Number of A&E attendances for accidents (0-19 years), by hospital. North West hospitals, 2011/12. Hospital Number of attendances Alder Hey Children’s Hospital 19,800 Arrowe Park Hospital 8,508 Blackpool Victoria Hospital 18,032 Burnley General Hospital 11,446 Chorley and South Ribble Hospital 8,555 Cumberland Infirmary 5,095 Furness General Hospital 1,690 Leighton Hospital 12,545 Macclesfield District General Hospital 7,793 Manchester Royal Infirmary 6,545 Ormskirk District General Hospital 5,604 Royal Albert Edward Infirmary 11,218 Royal Blackburn Hospital 10,247 Royal Bolton Hospital 11,442 Royal Lancaster Infirmary 5,385 Royal Liverpool University Hospital 1,997 Royal Preston Hospital 10,077 Salford Royal Hospital 6,289 Southport and Formby District General Hospital 904 Stepping Hill Hospital 11,393 Tameside Hospital 2,215 Trafford General Hospital 14,420 West Cumberland Hospital 3,621 Whiston Hospital 2,995 Wythenshaw Hospital 4,441 Total 202,257 Source: NWPHO from Trauma and Injury Intelligence Group 4.3.4 Type of injury

Three-quarters (75.1%) of attendances for accidents were classed as ‘other accident or injury’. Given the lack of further descriptive data it is not possible to specifically identify what types of injury these cases refer to. However, the information that is available shows that there were at least 19,800 attendances for falls and 19,800 for sports injuries (rates of 1,171.6 and 1,169.4 attendances per 100,000 population respectively) in 2011/12 (Figure 17). An additional 8,400 attendances (496.9 per 100,000) were due to a road traffic collision.

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Figure 17: Crude rate of A&E attendances for accidents (0-19 years) per 100,000 population, by type of injury. North West hospitals, 2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group and Office for National Statistics mid-year population estimates Note: ‘Other accidents or injuries’ is likely to include falls, sports injuries, road traffic injuries, burns and bites and stings that have not been specified as such. Analysis by age group shows that the highest rates of attendances for falls, burns and bites and stings are among those aged 0-4 years (1,687.1, 175.3 and 54.3 per 100,000 population respectively, Figure 18). Attendances for sports injuries are highest among the 10-14 year old population (2,239.6 per 100,000 population). Those aged 15-19 years have the highest attendance rate for road traffic injuries (885.1 per 100,000 population).

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Figure 18: Crude rate of A&E attendances for accidents by cause (0-19 years) per 100,000 population, by age group. North West hospitals, 2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group and Office for National Statistics mid-year population estimates Note: ‘Other accidents or injuries’ is likely to include falls, sports injuries, road traffic injuries, burns and bites and stings that have not been specified as such.

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4.3.5 Time of attendances

4.3.5.1 Month of year

Between April 2011 and March 2012, there were more A&E attendances in March (a daily average of 661.7 attendances) than in any other month (Figure 19). Numbers were also relatively high in April and May (645.6 and 648.2 daily attendances respectively) but lowest in December (383.1 attendances). Figure 19: Average number of daily A&E attendances for accidents (0-19 years), by month. North West hospitals, 2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group 4.3.5.2 Day of week

There were more A&E attendances for accidents recorded on a Monday (an average of 598.2 daily attendances) than any other day of the week (Figure 20). Attendances were also relatively high on a Sunday (577.9 attendances), but were lowest on a Saturday (515.4 attendances).

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Attendances at A&E peaked at 18.00-18.59 hours (accounting for 8.4% of all attendances for accidents among those aged 0-19 years). A further 8.3% of attendances occurred at 19.00-19.59 hours (Figure 21).

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Figure 21: Proportion of all A&E attendances for accidents (0-19 years), by hour of day. North West hospitals, 2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group 4.3.6 Other intelligence

A&E data collected via Hospital Episode Statistics are published nationally as experimental statistics. These are yet to be finalised given the limitations in the quality and coverage of records received via the A&E commissioning dataset. The data are not examined here but further details can be found on the NHS Information Centre website.xiii A recent study by the Centre for Public Health at Liverpool John Moores University which examined data for 0-14 year olds in England during 2010 used such data to better understand the types of injuries suffered by children and the groups most at risk from particular injuries.xiv It is important to note that this may differ to data extracted directly from Secondary Uses Service (SUS) data or from local patient administration systems. However, a key observation was that collection and collation of data between emergency departments is often inconsistent. Nonetheless, the analyses showed that injuries accounted for 45.1% of child attendances at English emergency departments with most (88.7%) being recorded as other unintentional injuries. All attendances for specified injuries, with the exception of sports injuries, increased with deprivation (even after controlling for age and gender). There were also considerable differences by age group, for example, burns peaked at age one, poisoning rose at ages one and two, and then again as children reached teenage years, while risk of sports injury increased steadily with increasing age.

xiii www.ic.nhs.uk/statistics-and-data-collections/hospital-care/accident-and-emergency-hospital-episode-statistics-hes/provisional-accident-and-emergency-quality-indicators-for-england-experimental-statistics-by-provider-for-june-2012 xiv The Centre for Public Health analysis also considers some intentional cases, such as from deliberate self-harm (DSH). Similarly the analysis refers to the patient group category and this does not include falls as a separate category, whereas some of the North West hospitals do. For more details see: www.datadictionary.nhs.uk/retired/data_dictionary/messages/commissioning_data_set_v5/accident_and_emergency_attendance_cds_type_fr.asp?shownav=1

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4.4 Ambulance data

Data on the location ambulances attended in response to a call from a member of the public are collected by the North West Ambulance Service. The crude rate of ambulance call-outs is not a full residence-based measure as the child requiring an ambulance may not live at the location where the ambulance was called to. It should also be noted that the location that an ambulance went to in response to a call may not be the exact location of the accident. However, the location of the site ambulances went to is recorded by lower super output area (LSOA) and therefore call-out rates can be calculated by level of deprivation. We examined data for the three-year period from 2009/10 to 2011/12. Each record in the ambulance dataset also includes information about the nature of the call-out.xv Some records in the dataset cannot be considered accidents, such as where the call-out was classified as being for an emergency transfer, breathing problem, chest pain or where the person had a heart problem. For the purpose of this report, we recoded these type of call-outs into an ‘other or not known’ category. Call-outs within this analysis of unintentional injuries in the North West included those already classified within the dataset as: • animal bites • burns • choking • drowning • electrocution • eye problems/injuries • falls • heat/cold exposure • inhaling hazardous substances • road traffic collisions • traumatic injuries

Within the analyses, data for these call-outs is therefore examined by individual type of injury and for all unintentional injuries or accidents as a group. Call-outs classified as poisoning within the dataset were not included in this analysis of unintentional injuries since the additional descriptive free text data for such cases available in the dataset showed that these clearly included both unintentional and intentional injuries (a typical comparison would be a small child accidentally drinking nail polish remover compared with a teenager who had self-poisoned). However, apart from individually reclassifying each case based on the individual descriptive text, there is no way of segregating these cases. As these are very different situations and would arguably require different public health preventative interventions, for the purpose of this analysis all poisonings were therefore classified as ‘other or not known’ call-outs rather than ‘all accidents’. However, the poisoning data has been referenced separately from the ‘all accidents’ analysis at the end of the section to provide the fullest possible information.

xv There are over 20 such classifications and some of these differ across the different years of data which were examined for the report.

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Between 2009/10 and 2011/12 there were a total of 283,279 ambulance call-outs to children and young people aged 0-19 years across the North West. In total, 21.5% of these call-outs, including 18,079 in 2011/12, were classified as due to an accident or injury. The other call-outs were classified for the purpose of this analysis as ‘other’ or ‘not known’.xvi Trend data show that there is evidence of a decrease in the number of ambulance call-outs over the last three years for injury related call-outs (Table 6). Table 6: Total number of ambulance call-outs among children and young people (0-19 years). North West, 2009/10 to 2011/12. 2009/10 2010/11 2011/12 Total All call-outs 97,838 91,371 94,070 283,279 Call-outs for accidents or injuries 22,216 20,700 18,079 60,995 Source: NWPHO from Trauma and Injury Intelligence Group 4.4.1 Local rates

There is considerable variation in the rates of ambulance call-outs due to accidents or injuries by local authority area (Figure 22, Map 2). Blackpool had the highest rate of call-outs (2,005.6 per 100,000 population) which is 2.4 times higher than the rate in the area with the lowest rate, Copeland (833.5 per 100,000). A total of 16 local authorities have rates that are significantly better than the North West average (Allerdale, Barrow-in-Furness, Carlisle, Cheshire East, Cheshire West and Chester, Chorley, Copeland, Lancaster, Oldham, Pendle, Ribble Valley, South Ribble, Stockport, Trafford, Warrington and West Lancashire ) while 5 areas have rates that are significantly worse (Blackpool, Liverpool, Manchester, Preston and Salford).

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Figure 22: Crude rate of ambulance call-outs for accidents (0-19 years) per 100,000 population. North West local authorities, 2009/10-2011/12.


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Map 2: Crude rate of ambulance call-outs for accidents (0-19 years), per 100,000 population. North West local authorities, 2009/10-2011/12.

Local authority Rate Allerdale 1,047.6 Barrow-in-Furness 1,066.1 Blackburn with Darwen 1,211.6 Blackpool 2,005.6 Bolton 1,160.6 Burnley 1,125.5 Bury 1,173.8 Carlisle 1,074.4 Cheshire East 910.1 Cheshire West and Chester 1,046.7 Chorley 878.4 Copeland 833.5 Eden 1,302.1 Fylde 1,146.9 Halton 1,286.0 Hyndburn 1,236.3 Knowsley 1,182.9 Lancaster 1,094.6 Liverpool 1,469.6 Manchester 1,710.1 Oldham 1,100.4 Pendle 958.5 Preston 1,379.4 Ribble Valley 983.3 Rochdale 1,158.4 Rossendale 1,134.0 Salford 1,334.5 Sefton 1,199.2 South Lakeland 1,266.2 South Ribble 1,023.0 St Helens 1,214.2 Stockport 1,065.8 Tameside 1,273.0 Trafford 1,019.4 Warrington 1,020.2 West Lancashire 1,122.2 Wigan 1,181.8 Wirral 1,221.2 Wyre 1,224.1 North West 1,212.4

Source: NWPHO from Trauma and Injury Intelligence Group and Office for National Statistics mid-year population estimates Crown copyright. All rights reserved. NWPHO/DH (licence 100020290). March 2013. Colour coding in the table represents the significance of the local rate compared with the North West average. Red = significantly worse; yellow = no significant difference; green = significantly better.

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4.4.2 Gender

Of those with a recorded gender,xvii 62.6% of ambulance call-outs for accidents among children and young people aged 0-19 years were for males. This gives a call-out rate of 1,470.4 per 100,000 population for males and 926.4 per 100,000 for females, a significant difference. 4.4.3 Age

The rate of ambulance call-outs for accidents for children and young people is highest among children aged 0-4 years (1,519.2 per 100,000 population, significantly higher than for any other age group), followed by young people aged 15-19 years (1,345.1 per 100,000) (Figure 23). The rate for children aged 0-4 years is 1.9 times higher than the rate for children aged 5-9 years. Figure 23: Crude rate of ambulance call-outs for accidents (0-19 years), by age group. North West, 2009/10-2011/12.


xvii 0.6% of ambulance call-outs for accidents did not have a recorded gender and were excluded from this analysis.

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The rate of call-outs for accidents and injuries significantly increases as deprivation increases (Figure 24). The rate in the most deprived areas is 2.3 times higher than the rate in the least deprived areas (1,630.0 compared with 698.9 per 100,000 population). Figure 24: Crude rate of ambulance call-outs for accidents (0-19 years) per 100,000 population, by Index of Multiple Deprivation 2010 quintile. North West, 2009/10-2010/11.

Source: NWPHO from Trauma and Injury Intelligence Group and Office for National Statistics mid-year population estimates Note: Population denominator data is for 2009 + (2010 x 2) as mid-year population estimates for 2011 are not yet available for lower super output areas. 4.4.5 Type of injury

Over the 2009/10-2011/12 period, the highest rate of ambulance call-outs among those aged 0-19 years was for falls (557.1 call-outs per 100,000 population, 46.0% of all call-outs for accidents) (Figure 25). The second most common accidental injury call-out cause was traumatic injuries (370.1 per 100,000, 30.5% of all call-outs for accidents). The rate of call-outs for road traffic collisions was 158.8 per 100,000 population, and accounted for 13.1% of call-outs for accidents, followed by call-outs for choking (52.2 per 100,000, 4.3%) and burns (38.4 per 100,000, 3.2%).

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Figure 25: Crude rate of ambulance call-outs for accidents (0-19 years) per 100,000 population, by type of injury. North West, 2009/10-2010/11.

Source: NWPHO from Trauma and Injury Intelligence Group and Office for National Statistics mid-year population estimates 4.4.5.1 Type of injury by age group

While falls are the most common accidental reason for an ambulance call-out among all age groups, the pattern of call-outs varies by cause and age group (Figure 26). The rate of ambulance call-outs for falls is highest among the youngest age group (0-4 years), at 809.4 per 100,000 population. The rate then more than halves among children aged 5-9 years, but then increases in older children. Ambulance call-outs for choking and burns are also highest among children aged 0-4 years (163.3 and 100.9 per 100,000 respectively), accounting for two-thirds and four-fifths of all call-outs for these causes among children and young people aged 0-19 years. However, call-outs for road traffic collisions have an opposite trend, being highest among those aged 15-19 years (247.8 per 100,000 population), and significantly lower among each consecutive lower age group. The rate of call-outs for traumatic injuries varies between each age group. The highest rate was among young people aged 15-19 years (496.3 per 100,000), followed by those aged 10-14 years (409.0), but the rate was lowest among those aged 5-9 years.

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Over the 2009/10-2011/12 period, there were an average of 55.7 ambulance call-outs for accidents each day for children and young people aged 0-19 years in the North West. However, there is some variation by day of the week: call-outs were highest on a Saturday (an average of 62.0 per day) and Sunday (59.9) and lowest on a Monday (50.6) and Tuesday (51.6) (Figure 38). Call-outs are highest in June (an average of 66.7 per day) and May (65.0) and lowest in December (41.1) and January (43.1) (Figure 28). These ambulance call-outs equate to 2.2 each hour over the period. Call-outs are highest between 15.00 and 19.59 (with a peak of an average of 4.5 call-outs per hour at 15.00-15.59) and are lowest between 3.00 and 7.59 (with a low of 0.2 call-outs per hour at 5.00-5.59 and 6.00-6.59) (Figure 29). Figure 27: Average daily call-outs for accidents (0-19 years), by day of week. North West, 2009/10-2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group

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Figure 28: Average daily call-outs for accidents (0-19 years), by month. North West, 2009/10-2011/12.

Source: NWPHO from Trauma and Injury Intelligence Group Figure 29: Average hourly call-outs for accidents (0-19 years), by hour of day. North West, 2009/10-2011/12.

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4.4.7 Ambulance call-outs due to poisoning

In the three years between 2009/10 and 2011/12 poisoning accounted for 16,215 ambulance call-outs among children and young people aged 0-19 years in the North West. However, we did not include these call-outs within our analysis of call-outs for accidents because these cases include both intentional and unintentional poisoning, but these differences are not flagged within standard coding in the dataset. The majority (78.5%) of call-outs for poisoning among children and young people aged 0-19 years were for those aged 15-19 years. A significant number of these are likely to be for intentional poisonings as is indicated by the descriptive free text data within the dataset. There is also substantial evidence that self-poisoning is more prevalent in this age group than any other.29 However, there were 1,301 call-outs for poisoning for children aged 0-4 years, 298 in 2011/12 (Table 7). Brief examination of the free-text field within the dataset shows that many of these cases include the ingestion of substances such as paracetamol, bleach, turps, nicotine lozenges, air fresheners and washing up tablets. Table 7: Total number of ambulance call-outs among children and young people (0-19 years) due to poisoning. North West, 2009/10 to 2011/12. Call-outs due to poisoning 2009/10 2010/11 2011/12 2009/10-2011/12 0-4 years 532 471 298 1,301 0-19 years 6,680 6,056 3,479 16,215 Source: NWPHO from Trauma and Injury Intelligence Group

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4.5 Road traffic injuries

Data on personal injury road traffic collisions and the casualties resulting from them are collected by the police and submitted to the Department for Transport through a system known as STATS19. Records for each collision and its circumstances, vehicle involved in the collision, and casualty resulting from the injury collision, are collected and reported. These statistics are essential for informing and monitoring road safety policy and initiatives, and provide evidence to support road safety education and enforcement as well as remedial engineering work. It has long been acknowledged that STATS19 is not a comprehensive record of all injury road traffic collisions and casualties. While very few, if any, fatalities are not known by the police, a large number of less serious collisions are not reported, as police do not attend all collisions and there is no legal requirement to report collisions – including those that cause injury – as long as details are exchanged by those involved at the scene of the collision. However, STATS19 is the most detailed, consistent, complete and reliable source of data on road traffic collision casualties, and provides essential information for developing effective measures to reduce road casualties.30 Road Traffic Collisions and Casualties in the North West31 included some analyses of child road casualties up to the age of 15 years to reflect the previous Government’s national target to halve the number of this age group killed or seriously injured on the roads. However, in this section we have examined data on child road casualties from 0-19 years, to align with the rest of the report. In the North West in 2011, there were 5,389 child casualties (aged 0-19 years) as a result of road traffic collisions. Children and young people aged 0-19 years represented 23.0% of all casualties with a known age, compared with 20.6% across England. Of the 5,389 child casualties in the North West in 2011, 27 were fatally injured and 693 were seriously injured, equating to a fatality rate of 5.0 per 1,000 casualties and a killed or seriously injured rate of 133.6 per 1,000 casualties. Of all the casualties with a known age killed or seriously injured in the North West, 24.6% were children or young people, compared with 20.8% across England. Further information in this section related to a three-year average time period (2009-11). STATS19 severity of injury definitions (fatal, serious and slight) are detailed in the appendices. 4.5.1 Regional rates

Compared with England and the English regions, the North West has a high child casualty rate for road traffic collisions. The North West child casualty rate (354.1 per 100,000 population) is the second highest regional rate in England, following the Yorkshire and the Humber rate of 369.5 per 100,000 (Figure 30). The North West rate is significantly higher than the England average (313.2 per 100,000) and the seven other English regional rates below it.

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Figure 30: Crude rate of road casualties (0-19 years) per 100,000 population. English regions, 2009-11.

Source: NWPHO from STATS19 and Office for National Statistics mid-year population estimates

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The North West also has a high rate of killed or seriously injured (KSI) child road casualties compared with England and the English regions (Figure 31). The North West child KSI rate (45.1 per 100,000) is the second highest regional rate in England. The rate is significantly higher than the England average (38.2) and the rates in five other regions. Figure 31: Crude rate of children (0-19 years) killed or seriously injured in road traffic collisions per 100,000 population by region, 2009-11.


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The North West’s rate of pedestrian casualties for those aged 0-19 years is also the second highest regional rate in England, at 88.5 per 100,000, slightly below the rate for Yorkshire and the Humber (89.1) (Figure 32). The North West’s rate is significantly higher than the England average (72.0) and the remaining seven regions. Figure 32: Crude rate of pedestrian casualties (0-19 years) per 100,000 population by region, 2009-11.


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4.5.2 Local rates

4.5.2.1 All road casualties

Across the region in 2009-11, the child road casualty rate was 354.1 per 100,000 population. The variation between local authority districts was large: from 227.2 per 100,000 population in Stockport Valley to 558.2 per 100,000 in Preston, 2.5 times higher (Figure 33, Map 3). Stockport, Trafford, Tameside, Sefton, Wigan, Rochdale, St Helens, Knowsley, Bury, Oldham and Wirral had rates significantly better than the North West average, while Preston, Eden, Blackpool, Allerdale, Lancaster, Chorley, Wyre, South Ribble, Hyndburn, Ribble Valley, Carlisle, Cheshire East, Copeland, Fylde, Blackburn with Darwen and Warrington had rates that were significantly worse. However, with the North West regional child casualty rate falling so far above the England rate (Figure 30), it is important to acknowledge that the issue of high rates of child road casualties is apparent in wider areas throughout the North West, not just in the localities that have casualty rates that are above the North West average. For example, the child casualty rate is significantly higher than the England average in 24 of the 39 local authority areas in the North West. Figure 33: Crude rate of road casualties (0-19 years) per 100,000 population. North West local authorities, 2009-11.


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Map 3: Crude rate of road casualties (0-19 years) per 100,000 population. North West local authorities, 2009-11.

Local authority Rate Allerdale 476.0 Barrow-in-Furness 299.4 Blackburn with Darwen 398.9 Blackpool 529.1 Bolton 345.4 Burnley 398.7 Bury 297.6 Carlisle 431.8 Cheshire East 421.2 Cheshire West and Chester 375.2 Chorley 461.3 Copeland 421.1 Eden 537.2 Fylde 419.5 Halton 332.0 Hyndburn 442.1 Knowsley 286.7 Lancaster 474.6 Liverpool 378.3 Manchester 365.1 Oldham 311.4 Pendle 317.6 Preston 558.2 Ribble Valley 432.6 Rochdale 279.8 Rossendale 394.9 Salford 332.6 Sefton 268.5 South Lakeland 370.2 South Ribble 449.1 St Helens 280.9 Stockport 227.2 Tameside 264.9 Trafford 228.4 Warrington 396.9 West Lancashire 390.9 Wigan 279.7 Wirral 313.3 Wyre 452.9 North West 354.1 England 313.2

Source: NWPHO from NWPHO from STATS19 and Office for National Statistics mid-year population estimates Crown copyright. All rights reserved. NWPHO/DH (licence 100020290). March 2013. Colour coding in the table represents the significance of the local rate compared with the North West average. Red = significantly worse; yellow = no significant difference; green = significantly better.

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4.5.2.2 Killed or seriously injured road casualties

In 2009-11, the killed or seriously injured child road casualty rate was 45.1 per 100,000 population in the North West, but local rates varied from 19.0 in Trafford to 91.8 in Burnley (Figure 34, Map 4). Trafford, Stockport, Rochdale, Wigan, Sefton and Tameside had rates that were significantly better than the North West average, while Burnley, Eden, Hyndburn, Allerdale, Ribble Valley, Chorley, South Ribble, Blackburn with Darwen, Preston and Cheshire East had rates that were significantly worse. However, only Trafford, Stockport and Rochdale had rates that were significantly better than the England average, while 15 local authorities had rates that were significantly worse. Figure 34: Crude rate of killed or seriously injured road casualties (0-19 years) per 100,000 population. North West local authorities, 2009-11.


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Map 4: Crude rate of killed or seriously injured road casualties (0-19 years) per 100,000 population. North West local authorities, 2009-11.



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4.5.2.3 Pedestrian casualties

In 2009-11, the killed or seriously injured road casualty rate for those aged 0-19 years was 88.5 per 100,000 population in the North West, but local rates varied from 26.2 in Fylde to 165.9 in Blackpool (Figure 35, Map 5). This means that the pedestrian casualty rate is 6.3 times higher in the local authority with the worse rate in the North West compared with the local authority with the best rate. Fylde, South Lakeland, West Lancashire, Trafford, Cheshire West and Chester, Cheshire East, Chorley, South Ribble, Wirral and Stockport had rates that were significantly better than the North West average, while Blackpool, Hyndburn, Preston, Blackburn with Darwen, Oldham, Burnley, Bolton, Manchester and Liverpool had rates that were significantly worse. However, only Fylde, South Lakeland, West Lancashire, Trafford, Cheshire West and Chester and Cheshire East had rates that were significantly better than the England average, while 15 local authorities had rates that were significantly worse. Figure 35: Crude rate of pedestrian casualties (0-19 years) per 100,000 population. North West local authorities, 2009-11.


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Map 5: Crude rate of pedestrian casualties (0-19 years) per 100,000 population. North West local authorities, 2009-11.



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4.5.3 Gender

More young males are injured in road traffic collisions than young females (58.7% of all casualties compared with 41.3%) (Table 8). This difference is more pronounced for fatal and serious injuries. Around seven out of ten of those killed or seriously injured are males. Young males of all age groups (0-4, 5-9, 10-14 and 15-19 years) are significantly more likely than young females of each respective age group to be a road casualty. Table 8: Severity of road casualties (0-19 years), by gender. North West, 2009-11. Fatal Serious Slight All casualties Males 71.4% 71.2% 56.8% 58.7% Females 28.6% 28.8% 43.2% 41.3% Source: NWPHO from STATS19

4.5.4 Age

The road casualty rate significantly increases as age increases (Figure 36). The rate for those aged 15-19 years (703.1 per 100,000 population) is 6.8 times the rate for those aged 0-4 years (104.0). Young people aged 15-19 years are also twice as likely as those aged 10-14 to be a road casualty. Figure 36: Crude rate of road casualties (0-19 years) per 100,000 population, by age group. North West, 2009-11.

Source: NWPHO from STATS19 and Office for National Statistics mid-year population estimates However, analysis of road casualty rates by single year of age reveals further differences in risk between consecutive single-year cohorts of children and young people, especially for young people in their mid to late teens (Figure 37).

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The casualty rate for 11 year olds (389.7 per 100,000) is significantly higher than for 10 year olds (314.6 per 100,000). This increased risk is predominately in relation to pedestrian and cyclist casualties with the increases in rates between 10 and 11 year olds being 68.5% and 13.1% respectively, and occurs at a critical time for children – as they move from primary to secondary school. In total, 47.1% of 11-year-old road casualties are pedestrians. The most visible, and significant, differences are between children aged 15 and 16 years, and 16 and 17 years. Children aged 16 years are significantly more likely to be a road traffic casualty than 15 year olds (a rate of 524.8 per 100,000 compared with 343.4), while 17 year olds are significantly more likely than 16 year olds to be a casualty, a rate of 791.6 per 100,000 compared with 524.8. Between 15 and 16 years, the difference is mainly due to the increase in moped rider or passenger casualties, with 16 year olds being 26.3 times more likely to be a moped casualty than 15 year olds (with 25.1% of all 16-year-old road casualties being a moped rider or passenger). Between 16 and 17 years, the rate of car occupant casualties significantly increases – with the casualty risk increasing by 2.6 times. Of all 17-year-old road casualties, 60% are injured this way. The motorcycle rider or passenger casualty rate is lower (13.7% of 17-year-old casualties), but the rate also increases between 16 and 17, by 6.0 times. The road casualty rate is higher still for 18 year olds (962.9 per 100,000, significantly higher than any other single year cohort), with car occupant casualties increasing further. Of all 18-year-old road casualties, 71.4% are car occupants. Figure 37: Crude rate of road casualties (0-19 years) per 100,000 population, by single year of age. North West, 2009-11.


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Analysis of STATS19 data by deprivation level of where the collision occurred is only possible for the most recent year of data, 2011. However, this suggests there is some relationship between child casualties and deprivation with rates being lowest in the least deprived and highest in the most deprived (78.1 per 100,000 and 115.5 per 100,000 respectively) (Figure 38). Figure 38: Crude rate of road casualties (0-19 years) per 100,000 population, by Index of Multiple Deprivation 2010 quintile. North West, 2011.

Source: NWPHO from STATS19, Office for National Statistics mid-year population estimates and Department for Communities and Local Government 4.5.6 Road user type

One half (50.7%, 3,012 per year) of all child road casualties aged 0-19 years in the North West are car occupants while one-fifth (25.0%, 1,484 per year) are pedestrians and one tenth (10.0%, 591 per year) are cyclists. Smaller proportions are motor cycle riders or passengers (4.8%, 282 per year) or moped riders or passengers (3.3%, 193 per year). However, as previously noted, the type of road casualty varies by age. Pedestrian and cyclist casualty rates are highest among those aged 10-14 years, while car occupant, motorcycle rider or passenger and moped rider or passenger casualty rates are highest among those aged 15-19 years (Figure 39).

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Figure 39: Crude rate of road casualties (0-19 years) per 100,000 population, by road user type and age group, 2009-11.


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5. Summaries by injury cause

The following section summarises the key messages arising from the data examined in the report for the most common injury causes. Where possible some indication of the costs arising from injuries is highlighted along with details of where possible public health interventions could best be targeted. A key finding overall is that greater consistency and standardisation, particularly in the collection of A&E and ambulance data, would enhance the available evidence base and the potential for development of appropriate and timely public health interventions. 5.1 Falls

• There were 8,729 emergency hospital admissions for falls in 2011/12 in the North West, making this the most common reason for emergency admission due to accidents or injuries in childhood. The majority require a stay in hospital of three days or less.

• Falls also accounted for 8,611 ambulance call-outs due to accidents among children in the North West (equating to just under half of all ambulance call-outs for accidents in childhood) and a total of 19,803 A&E attendances in 2011/12. Given the limitations in the coding of ambulance and A&E data, the burden of falls is likely to be greater still.

• Head injuries are the most common severe injury among children and the Child Accident Prevention Trust (CAPT) note that falls, such as from a window, down stairs or from a high chair, are a leading cause of such harms in children.xviii,32 The approximate lifetime medical, educational and social costs for one child with a serious traumatic brain injury are in the region of £4.89 million.

• The costs of emergency ambulance journeys are estimated to be around £300.33 These estimates consider equipment and vehicle costs, building costs, salaries and any overheads. This suggests that in 2011/12 ambulance call-outs alone due to falls in the North West cost in the region of £2,583,300.

• Research by CAPT has also shown that (where the place of accident is known) accidents at home account for 80% of admissions to hospital for unintentional accidents among the under 5s (excluding transport accidents), decreasing to 50% among the under 18s.8 This suggests that the home environment should be a key focus of interventions designed to reduce prevalence of falls, but especially among the youngest age groups.

• Preventing falls is of paramount importance across the North West among all age groups, but especially within the youngest age groups where the risk of falls is greatest.

• In future research, hospital admissions data could be examined in greater depth to determine the specific types of injury resulting from falls and the relationships between deprivation and falls.

5.2 Road traffic collisions

• Road traffic collisions are the main cause of accidental death among children and young people. Older children (15-19 years) are especially likely to die in those traffic collisions in which they are car occupants.

• Police incident data shows that there were 5,389 child casualties (aged 0-19 years) as a result of road traffic collisions in the North West during 2011 (with 720 of these being fatal or seriously injured casualties).

• The rate of child road casualties in the North West is high compared with other regions.

xviii Road traffic collisions are the second leading cause. 68

• The most recent estimates produced by the Department for Transport suggest that the average cost per seriously injured casualty (based on casualties of all ages) on the roads is £189,519 while the average cost per fatality is now £1.69 million.32 Such estimates cover the human costs such as pain, grief and suffering (using a ‘willingness to pay’ approach), the direct economic costs of lost output (most relevant to children if they suffer injuries resulting in lifelong problems) and the medical costs associated with road accidents. If applied to the data within this report, these estimates suggest that the cost of the number of children fatally or seriously injured in 2011 in the North West could potentially be £177 million.

• There were 2,379 emergency hospital admissions due to transport accidents in 2011, 2,413 ambulance call-outs, and 8,398 A&E attendances in 2011/12 among 0-19 year olds.

• Reducing the rate of child casualties in the region should therefore be a key priority for the North West. Interventions should be focussed upon males and young people in their later teenage years as these are the groups who are most at risk. However, there are also other groups that should be considered (e.g. pedestrian safety among children moving from primary to secondary school).

5.3 Burns, scalds and exposure to smoke, fire or flames

• Exposure to smoke, fire and flames were responsible for 2.2% of accidental deaths in childhood nationally in 2007-11.

• Contact with heat and hot surfaces is responsible for 742 admissions in 2011/12 with the under 5s being particularly at risk (accounting for 581, or 78.3%, of these admissions). Although exposure to smoke fire and flames was responsible for far fewer admissions in 2011/12 (96xix children or young people) these tend to result in some of the longest stays in hospital overall (with almost one in five stays requiring a stay in hospital of four or more days).

• The burden is greater still if further data is considered: there were 640 ambulance call-outs for burns and a further 1,502 A&E attendances for burns in 2011/12.

• CAPT also note that burns injuries are most common among the under 5s. Treatment for burns is very costly, but especially where the resulting injuries are severe: for example, the cost of a day in a specialist burns unit (£750 for minor and £2,500 for a more serious burn) can therefore be triple the costs for a bed on a normal hospital ward.

• The average cost of inpatient treatment for a major burn (covering 30-40% of body) including high dependency unit care is therefore £63,157.32,34

• Therefore, if we were to assume that the 17 children hospitalised for four or more days in 2011/12 represent the most severe cases, the cost could potentially be over £1 million.

• It is important to note that a child with a burn is also likely to require long-term treatment after being discharged from hospital which can include: • dressings and post-discharge clinic visits • pressure garments • scar review consultations • surgical procedures • annual outpatient appointments • psychological therapy

xix With known duration - 99 in total 69

• Therefore, the follow up costs are considerable. A severe scald from bath water could, for example, result in up to 16 years of additional treatment, costing anywhere between £16,116 to £50,000 for the most severe.34

5.4 Other injuries

Poisoning

• Accidental poisoning is responsible for 7.2% of accidental deaths among children in 2007-11 and it accounts for considerable numbers of emergency hospital admissions each year (1,368 specifically in 2011/12) with the youngest and oldest groups of children being most at risk.

• There were also 3,479 ambulance call-outs for poisoning in 2011/12 with most generally being concentrated among 15-19 year olds. It is not possible to easily or accurately identify those poisonings that were accidental within the A&E data.

• Even in those datasets where cases of poisoning are coded as accidental (such as with hospital admissions) it is likely that these will include a mixture of intentional and unintentional acts given the overwhelming numbers of teenagers in the figures.

• Regardless of these limitations and the implications for planning public health interventions, the costs are considerable. Poisoning among children aged under 15 costs the NHS around £2 million annually.35

• Medicines are generally the main reason for poisoning admissions, most commonly through everyday painkillers and household cleaning products. The impacts of poisoning with bleach for example are considerable for a young child, leading to: • damage to the gullet • the need for numerous operations through childhood and into adulthood • considerable individual healthcare costs • feelings of guilt among family members

• Interventions to tackle accidental poisonings need to focus upon the youngest age group.

Choking

• Choking accounted for 11.4% of accidental deaths among children in England. The youngest children are particularly at risk from this type of accident.

• There were 796 ambulance call-outs for choking in 2011/12. • Hospital admissions classed as other accidental threats to breathing (which can include

cases of choking) caused 125 emergency admissions in 2011/12, with the youngest children being particularly at risk.

• Cases of choking are not specifically recorded in the A&E data but it is likely that such cases are included within the other accident or injury group.

Sports injury

• Sports injuries accounted for 19,765 A&E attendances in 2011/12 and were most prevalent among 10-14 year olds.

• Such injuries are not specifically noted in the hospital admissions external cause data or ambulance data and therefore further analyses are limited.

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Drowning

• Nationally, 6.6% of children aged 0-19 years who died accidentally in 2007-11 drowned, with young children being most at risk.

• Emergency hospital admissions data showed 15 cases of drowning in 2011/12 and only 2 cases according to the A&E attendance data, but there were 50 ambulance call-outs for drowning in the same period.

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6. Accidents and injuries by age group

This section summarises some of the key data in relation to each of the four age groups examined in the report. The aim is to help identify the major accident and injury risks throughout the different stages of development in a child’s or young person’s life. Data limitations have already been noted in the report, particularly for the cause of injury in A&E attendance data. Better and more uniform reporting of injuries would further enhance our understanding of the causes and types of injuries among children and young people, and subsequent planning of appropriate responses or interventions.

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Table 9: Summary of child accident and injury intelligence, by five-year age group Key facts 0-4 years 5-9 years 10-14 years 15-19 years Numbers of deaths from accidents, mortality rate and mortality rate compared with other age groups (England, 2011)

• 68 deaths • 2.0 per 100,000 • Second highest

• 30 deaths • 1.0 per 100,000 • Lowest rate

• 38 deaths • 1.2 per 100,000 • Third highest

• 216 deaths • 6.5 per 100,000 • Highest rate

Mortality rate trend, and comparison with other age groups (England, 2007 to 2011)

• Decreased by 23.4% • Other age groups had

proportionately higher decreases.

• Decreased by 31.5% • Older age groups had

proportionately higher decreases.

• Decreased by 56.0% • Largest proportionate

decrease of all age groups.

• Decreased by 47.6% • Second largest

proportionate decrease.

Proportion of all deaths with an accidental cause (North West, 2007-11)

2.4% (11.5% among 1-4 year olds)

13.1%

21.1% 29.9%

Top three causes of accidental death (England, 2007-11)

1) other accidental threats to breathing;

2) accidental drowning and submersion; and

3) being a pedestrian injured in a transport accident.

1) being a pedestrian injured in a transport accident;

2) being a car occupant injured in a transport accident; and

3) other accidental threats to breathing.

1) being a pedestrian injured in a transport accident;

2) other accidental threats to breathing; and 3) being a car occupant

injured in a transport accident.

1) being a car occupant injured in a transport accident;

2) being a motorcycle rider injured in a transport accident; and

3) being a pedestrian injured in a transport accident.

Numbers of emergency hospital admissions, rate per 100,000 and admission rate compared with other age groups (North West, 2011/12)

• 7,563 admissions • 1,746.7 per 100,000 • highest rate

• 4,070 admissions • 1,031.7 per 100,000 • second highest rate

• 3,935 admissions • 960.5 per 100,000 • third highest rate

• 3,599 admissions • 794.3 per 100,000 • lowest rate

Hospital admission trends over last five years (North West, 2007/08 to 2011/12)

• Increase of 15.9% in admission rate for accidents

• Driven by an increase in the admission rate for those aged 0 and 1 year of age (+27.4% and +22.6% respectively).

No discernible trend

No discernible trend • Decrease of 17.0% in admission rate for accidents

Top three accidental causes of hospital

1) falls; 2) exposure to inanimate




74

Key facts 0-4 years 5-9 years 10-14 years 15-19 years admissions (North West, 2011/12)

mechanical forces; and 3) accidental poisoning by

exposure to noxious substances.

mechanical forces; and 3) being a pedal cyclist injured

in a transport accident.

mechanical forces; and 3) being a pedal cyclist injured

in a transport accident.

mechanical forces; and 3) accidental poisoning by

exposure to noxious substances.

Hospital admission rates for injury causes compared with other age groups (North West, 2011/12)

Highest rates for: • falls; • exposure to inanimate

mechanical forces; • accidental poisoning by

exposure to noxious substances;

• accidental exposure to other unspecified factors; and

• contact with heat and hot substances.

N/A Highest rates for: • being a pedal cyclist injured

in a transport accident; • exposure to animate

mechanical forces; and • being a pedestrian injured in

a transport accident.

Highest rates for: • being a car occupant

injured in a transport accidents; and

• being a motorcycle rider injured in a transport accident.

Hospital admission rates for specific falls causes compared with other age groups (North West, 2011/12)

Highest rates for: • falls on the same level from

slipping, tripping and stumbling

• falls on and from stairs and steps

• other falls on the same level • falls involving a bed • falls involving a chair • falls while being carried or

supported by other persons

Highest rate for: • falls involving playground

equipment

Highest rate for: • falls on the same level due

to collision with, or pushing by, another person

• falls involving ice-skates, skis, roller-skates or skateboards

N/A

Numbers of A&E attendances, rate per 100,000 and rate compared with other age groups (North West, 2011/12)

• 54,663 attendances • 12,624.7 per 100,000 • Second highest rate

• 39,306 attendances • 9,964.1 per 100,000 • Lowest rate

• 56,286 attendances • 13,739.4 per 100,000 • Highest rate

• 52,002 attendances • 11.477.5 per 100,000 • Third highest rate

A&E attendance rate by causes compared with other age groups

Highest rate for: • falls • bites, burns and stings

N/A Highest rate for: • sports injuries

Highest rate for: • road traffic injuries

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Key facts 0-4 years 5-9 years 10-14 years 15-19 years Average annual number of ambulance call-outs, rate per 100,000 and rate compared with other age groups (North West, 2009/10-2011/12)

• 6,496 call-outs • 1,519.2 per 100,000 • Highest rate

• 3,102 call-outs • 803.4 per 100,000 • Lowest rate

• 4,595 call-outs • 1,129.3 per 100,000 • Third highest rate

• 6,138 call-outs • 1,345.1 per 100,000 • Second highest rate

Causes of ambulance call-outs compared with other age groups (North West, 2009/10-2011/12)

Highest rates for: • falls • choking • burns

N/A N/A Highest rate for: • road traffic injuries • traumatic injuries

Average number of road traffic casualties per year, rate per 100,000 and rate compared with other age groups (North West, 2009-11)

• 445 casualties • 104.0 per 100,000 • Lowest rate

• 889 casualties • 230.2 per 100,000 • Third highest rate

• 1,396 casualties • 343.1 per 100,000 • Second highest rate

• 3,208 casualties • 703.1 per 100,000 • Highest rate

Road traffic casualties by cause compared with other age groups (North West 2009-11)

N/A

N/A Highest rate for: • pedestrians • cyclists

Highest rate for: • car occupants • motorcycle riders or

passengers • moped riders or passengers

Source: NWPHO from Hospital Episode Statistics, Office for National Statistics (mortality datasets and mid-year population statistics), Trauma and Injury Intelligence Group (ambulance call-outs, A&E attendances) and STATS19

7. Appendices

Appendix 1 Causes of accidents and injury (International Classification of Disease-10 [ICD-10] code summary groups) ICD-10 codes Injury group

V01-X59 Accidents V01-V99 Transport accidents V01-V09 Pedestrian injured in transport accident

V10-V19 Pedal cyclist injured in transport accident V20-V29 Motorcycle rider injured in transport accident V30-V39 Occupant of three-wheeled motor vehicle injured in transport accident V40-V49 Car occupant injured in transport accident V50-V59 Occupant of pick-up truck or van injured in transport accident V60-V69 Occupant of heavy transport vehicle injured in transport accident V70-V79 Bus occupant injured in transport accident V80-V89 Other land transport accidents V90-V94 Water transport accidents V95-V97 Air and space transport accidents V98-V99 Other and unspecified transport accidents W00-X59 Other external causes of accidental injury

W00-W19 Falls W20-W49 Exposure to inanimate mechanical forces W50-W64 Exposure to animate mechanical forces W65-W74 Accidental drowning and submersion W75-W84 Other accidental threats to breathing W85-W99 Exposure to electric current, radiation and extreme ambient air temperature

X00-X09 Exposure to smoke, fire and flames X10-X19 Contact with heat and hot substances X20-X29 Contact with venomous animals and plants X30-X39 Exposure to forces of nature X40-X49 Accidental poisoning by and exposure to noxious substances X50-X57 Overexertion, travel and privation X58-X59 Accidental exposure to other and unspecified factors Source: WHO ICD-10 classification of diseases – external cause codes (http://apps.who.int/classifications/icd10/browse/2010/en#/XX)

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http://apps.who.int/classifications/icd10/browse/2010/en%23/V01-V09














http://apps.who.int/classifications/icd10/browse/2010/en%23/W00-W19





http://apps.who.int/classifications/icd10/browse/2010/en%23/X00-X09







http://apps.who.int/classifications/icd10/browse/2010/en%23/XX

Appendix 2 Preventing accidents in childhood

There is a variety of evidence about interventions that can help prevent unintentional accidents and injuries occurring in childhood; examples include adaptations to a child’s environment, the fitting of safety devices (e.g. smoke alarms are shown to be the most successful), providing education or skills training and the delivery of multi-component interventions. Effective supervision is also known to be a key means of preventing harm to children but this can vary by for example the parent’s mental health, confidence level or use of alcohol and drugs.2 Useful organisations:

Child Accident Prevention Trust (CAPT) - a national charity committed to reducing the number of children and young people killed, disabled and injured as a result of accidents. Child and Maternal Health Observatory (ChiMat) provides information and intelligence to improve decision-making for high quality, cost effective services. ChiMat will be part of Public Health England from 1 April 2013. European Child Safety Alliance - launched in 2000 to reduce the leading cause of death - injury - in every member state region (www.childsafetyeurope.org). Has operated out of the Royal Society for the Prevention of Accidents in Birmingham since January 2011. TACTICS- large scale multi-year initiative to provide better information, practical tools and resources to prevent injury (builds on the child safety action plan project) Keeping Children Safe at Home (KCSH) - a major research project (CAPT are the only charity involved with the project) which aims to improve understanding of children's accidents and effect a change in behaviour with parents and families around child safety. Funded by the National Institute for Health Research (NIHR), the project runs from 2009-2014. Making the Link - is a programme supported by the Department for Education (DfE) and the Department of Health (DH) and run by CAPT to support people whose remit is to prevent child accidents throughout England. Royal Society for the Prevention of Accidents (ROPSA) - registered charity aiming to prevent accidents, while striking the right balance between prescription and individual choice. The Trauma and Injury Intelligence Group (TIIG) - established to look at access to quality and reliable injury information. A major element of TIIG is the establishment of an Injury Surveillance System (ISS) across the North West. Whoops - is the only child safety training project of its kind in the UK (based in the North East). They note on their website that every year in the UK, the equivalent of two primary schools full of children will die as a result of an accident with many further children injured, disabled or scarred through accidents. www.safekids.co.uk - practical tips, advice and guidance. www.safenetwork.org.uk - provide safeguarding information to support the voluntary sector. Youthsafe - provides evidence reviews for preventing accidents among the 15-24 age group.

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http://www.childsafetyeurope.org/

http://www.education.gov.uk/

http://www.dh.gov.uk/en/index.htm

http://www.capt.org.uk/

http://www.safekids.co.uk/

http://www.safenetwork.org.uk/

Appendix 3 'Fatal' injury includes only those cases where death occurs in less than 30 days as a result of the collision. 'Fatal' does not include death from natural causes or suicide. Examples of 'serious' injury Fracture Internal injury Severe cuts Crushing Burns (excluding friction burns) Concussion Severe general shock requiring hospital treatment Detention in hospital as an in-patient, either immediately or later Injuries to casualties who die 30 or more days after the collision from injuries sustained in that collision. Examples of 'slight' injury Sprains, not necessarily requiring medical treatment Neck whiplash injury Bruises Slight cuts Slight shock requiring roadside attention. (Persons who are merely shaken and who have no other injury should not be included unless they receive or appear to need medical treatment). Source: Department for Transport (definitions, symbols and conventions)

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Appendix 4: Summary table for North West local authorities

Local authority

Hospital admissions (crude rate) N

umb

er p

er

year

Co

mp

ared

wit

h th

e N

ort

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wit

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Ambulance call-outs

(crude rate) Ave

rag

e nu

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per

yea

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wit

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Road traffic injuries

(crude rate) Ave

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Road traffic KSI (crude

rate) Ave

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wit

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Pedestrian casualties

(crude rate) Ave

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nd

Allerdale 1,009.2 211 1,047.6 219 476.0 100 76.4 16 74.8 16 Barrow-in-Furness 1,056.5 168 1,066.1 176 299.4 49 34.4 6 95.1 16 Blackburn with Darwen 1,249.2 530 1,211.6 514 398.9 169 64.4 27 130.3 55 Blackpool 1,268.2 411 2,005.6 657 529.1 173 51.9 17 165.9 54 Bolton 1,043.4 747 1,160.6 814 345.4 242 36.1 25 119.7 84 Burnley 1,473.2 319 1,125.5 249 398.7 88 91.8 20 120.4 27 Bury 1,103.1 512 1,173.8 547 297.6 139 39.3 18 93.7 44 Carlisle 928.8 221 1,074.4 250 431.8 100 48.8 11 74.6 17 Cheshire East 1,099.9 919 910.1 758 421.2 351 63.7 53 57.7 48 Cheshire West and Chester 1,180.6 876 1,046.7 790 375.2 283 47.7 36 54.3 41 Chorley 1,065.5 261 878.4 212 461.3 111 71.8 17 59.4 14 Copeland 1,319.1 202 833.5 128 421.1 65 52.1 8 82.5 13 Eden 896.7 97 1,302.1 143 537.2 59 81.9 9 63.7 7 Fylde 832.5 128 1,146.9 175 419.5 64 30.6 5 26.2 4 Halton 1,172.9 368 1,286.0 396 332.0 102 36.8 11 76.8 24 Hyndburn 1,181.7 245 1,236.3 266 442.1 95 79.1 17 152.0 33 Knowsley 1,086.2 399 1,182.9 447 286.7 108 36.2 14 70.6 27 Lancaster 1,063.3 340 1,094.6 359 474.6 156 58.9 19 94.5 31 Liverpool 1,026.4 1,084 1,469.6 1,511 378.3 389 51.5 53 109.3 112 Manchester 1,360.4 1,743 1,710.1 2,059 365.1 440 37.9 46 117.6 142 Oldham 1,446.3 903 1,100.4 674 311.4 191 47.4 29 121.4 74 Pendle 1,189.4 270 958.5 220 317.6 73 59.5 14 97.2 22 Preston 1,151.4 405 1,379.4 469 558.2 190 63.8 22 141.3 48 Ribble Valley 1,108.2 148 983.3 133 432.6 59 76.2 10 59.0 8 Rochdale 1,266.5 713 1,158.4 640 279.8 155 25.3 14 98.3 54 Rossendale 1,153.8 192 1,134.0 194 394.9 68 54.5 9 77.8 13 Salford 1,326.3 759 1,334.5 730 332.6 182 34.7 19 87.1 48 Sefton 939.3 570 1,199.2 743 268.5 166 31.2 19 73.2 45 South Lakeland 924.3 189 1,266.2 271 370.2 79 34.2 7 35.8 8 South Ribble 1,024.9 258 1,023.0 257 449.1 113 65.1 16 61.1 15 St Helens 1,210.4 493 1,214.2 510 280.9 118 42.1 18 82.5 35 Stockport 991.5 664 1,065.8 713 227.2 152 22.9 15 69.3 46 Tameside 1,170.1 632 1,273.0 686 264.9 143 32.2 17 95.3 51 Trafford 833.9 474 1,019.4 555 228.4 124 19.0 10 53.9 29 Warrington 1,181.0 576 1,020.2 491 396.9 191 48.5 23 76.2 37 West Lancashire 1,101.6 288 1,122.2 296 390.9 103 45.5 12 45.5 12 Wigan 1,087.6 822 1,181.8 879 279.7 208 30.5 23 80.7 60 Wirral 1,048.8 788 1,221.2 915 313.3 235 44.5 33 67.6 51 Wyre 1,076.3 242 1,224.1 285 452.9 105 63.1 15 80.3 19 North West 1,134.0 19,167 1,212.4 354.1 45.1 88.5 England 940.9 313.2 38.2 72.0

Source: NWPHO from Hospital Episode Statistics, Trauma and Intelligence Group, STATS19 and Office for National Statistics mid-year population statistics. Colour coding in the table represents the significance of the local rate compared with the North West (or England) average. Red = significantly worse; yellow=no significant difference; green= significantly better.

8. References

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http://healthandcare.dh.gov.uk/public-health-system

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http://www.makingthelink.net/news/14-01-13/poisoning-how-reduce-hospital-admissions

http://www.makingthelink.net/news/14-01-13/poisoning-how-reduce-hospital-admissions

Child Accidents and Injuries in the North West 2013 Authors: Jennifer Mason, Lynn Deacon, Clare Perkins, Mark Bellis Acknowledgements We would like to acknowledge the support and input of our colleagues within the North West Public Health Observatory and/or Centre for Public Health, Liverpool John Moores University, who assisted us with the production of this report: Jenny Brizell, Rebecca Harrison, Phil McHale, David Nolan, Mark Robinson, Johnathan Rooney, Val Upton and Sacha Wyke. Special thanks to Eustace de Sousa, NHS North West, for championing the report.

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North West Public Health Observatory Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University 2nd Floor, Henry Cotton Campus 15-21 Webster Street Liverpool L3 2ET Tel: +44 (0)151 231 4535 Fax: +44 (0)151 231 4552 Email: [email protected] Web: www.nwpho.org.uk www.cph.org.uk www.chimat.org.uk Published: March 2013

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